Twice this past week we received two hospice pt's, two days apart, who were actively dying. Mind you these hospice pt's were DNR/DNI/DO NOT TOUCH ME I WANT TO DIE IN PEACE! One pt wasn't even in the ER 20 minutes and she passed. Thankfully the family made it to the hospital and was at the bedside. And it was a horrible night in the ED. We were getting our butts kicked bad. Every bed filled, flying out a critical, and several other critical pt's to care for. I was so angry that this poor pt was uprooted from her bed, taken from her normal surrondings, shoved in an ambulance and brought to us. The bright lights, hard beds, unfamiliar faces, weird sounds and sometimes horrible smells. What happened to dying with dignity in your own surrondings. But the nursing home didn't want to do the paperwork so they sent her to us. The pt's nurse was tied up with the critical pt being flown and I couldn't stand the family in there by themselves. Her sats were in the 60's, HR in the 20's and she was only giving an occasional gasp. I went in and stood by the bed quietly. I explained that her heart was slowly stopping and that her breathing would soon stop. After a few minutes I watched her heart go into v-fib then a few seconds later asystole. I stayed a few more minutes with the family until the other nurse could take over.
The next night again, another hospice pt, actively dying. This time because the dr. didn't want to give the hospice nurse V.O. to increase the morphine to make her comfortable without being medically cleared! Granted she was getting a pretty hefty dose of morphine Q1 hour, but her lungs were diminished in the bases and full of fluid you could hear her breathing from across the room. So, we had to do as the family and dr wished. Put her on bipap, put in an iv, push lasix yadda, yadda yadda. I believe these were comfort measures because it did help her breathing but the poor lady just wanted to be free from her pain. She did pass later that night.
I wholeheartedly agree -- this is one of the ugliest situations we encounter.
Many people *think* they want their family member to pass at home, but are not prepared for the reality of it. And then there is the uncertainty that creeps in over "new" symptoms -- does the patient have altered mental status as a result of progression in the dying process, or is it a UTI which is potentially correctable?
We as a culture need to seriously reexamine our ethical standards and realign them with our technological capabilities.
"As for the doctor who didn't want to give the morphine, that should have been handled by the hospice doctor and or nurse. Someone is always on call."
Dixie, it was the hospice nurse who called report to me and sent her in because the hospice doctor didn't want to increase the morphine without a medical evaluation and said to send her to the ER. The poor hospice nurse was doing everything she could, trying to keep her home and comfortable.
What frosts my behind are the nurses at LTC facilities that won't give morphine to a dying patient - "you're just trying to kill her". Come on - you call yourself a nurse? Oh, I had one case where Mom had signed DNR, living will w/instructions not to resusitate - wanted to be kept comfortable as possible and free from pain. This was all in writing. But daughter - who was a nurse -absolutely refused to go along with Mom's wishes and she died in the hospital from "respiratory distress" after having breathing tube, etc. I found I became very jaded and exasperate after a while - come on, it's not about what you want it's about honoring your Mom/Dad/significant others wishes. This area of the country is not hospice friendly at all, especially the MD's. Which is I'm not doing hospice any more! Got tired of beating my head against the wall.
We had a poor lady - not very old - who was dragged in (bullied I think) to our ED by various family members. She was end stage COAD. There was nothing we could do except put her on oxygen; I don't even think she was written up for any diuretics (she wasn't my patient, I was only helping out that night). The family were like DO something to help her - basically to keep her from dying. There was NOTHING else we could do. I felt sorry for this woman, on this hard barouche, gasping for breath, the family all squabbling, kids jumping around everywhere & trying to sit on the barouche (they aren't even big enough for that). I tried to make her as comfortable as possible, but I felt like saying: we cannot stop her from dying. Just take her home, make her comfortable & just BE with her before she dies.
It's very cruel & unnecessary to do this to a person. The docs should take a firmer stance with the families I think.
Who wants to die in a cold, busy ED? My parents will not be going that way, I can tell you now.
Many societies face death, ie: Irish & Scottish used to have the open coffin so kids, relatives could see their loved one one last time & pay their respects (I know this is not always possible due to trauma).
But western society in the main does not accept death. Children aren't brought up to accept it. As recent as the 1970's, people were not told they were dying, in hospital or at home.
My Mum remembers visiting an elderly relative of hers, who was dying from cancer and her mum warned her not to tell the patient she was dying. The docs/nurses never told them either, it was considered kinder not to.
I think there are things we all need to be educated about better, the biggies being life & death.
And I don't know if anyone could really be brought up to 'accept' death, but being told the realities of death at an appropriate age might help everyone deal with it better.
It sounds like more education is needed in regards to the role of Hospice in a facility. Those poor patients.
Families need more education for sure.. like how dehydration can actually cause euphoria in dying patients, and by hydrating them will cause them more discomfort. MDs not specifically trained in hospice care need to attend CEUs to be OK with prescribing large doses of narcs for these pts, aides and family members need to be educated about the dying process and what to expect from their loved ones like how they are going to breathe, etc, and what it means to be on hospice care and what it means to call 911. Call 911 and it's full code again unless the proper paperwork accompanies that person.
Twice this past week we received two hospice pt's, two days apart, who were actively dying. Mind you these hospice pt's were DNR/DNI/DO NOT TOUCH ME I WANT TO DIE IN PEACE! One pt wasn't even in the ER 20 minutes and she passed. Thankfully the family made it to the hospital and was at the bedside. And it was a horrible night in the ED. We were getting our butts kicked bad. Every bed filled, flying out a critical, and several other critical pt's to care for. I was so angry that this poor pt was uprooted from her bed, taken from her normal surrondings, shoved in an ambulance and brought to us. The bright lights, hard beds, unfamiliar faces, weird sounds and sometimes horrible smells. What happened to dying with dignity in your own surrondings. But the nursing home didn't want to do the paperwork so they sent her to us. The pt's nurse was tied up with the critical pt being flown and I couldn't stand the family in there by themselves. Her sats were in the 60's, HR in the 20's and she was only giving an occasional gasp. I went in and stood by the bed quietly. I explained that her heart was slowly stopping and that her breathing would soon stop. After a few minutes I watched her heart go into v-fib then a few seconds later asystole. I stayed a few more minutes with the family until the other nurse could take over.
The next night again, another hospice pt, actively dying. This time because the dr. didn't want to give the hospice nurse V.O. to increase the morphine to make her comfortable without being medically cleared! Granted she was getting a pretty hefty dose of morphine Q1 hour, but her lungs were diminished in the bases and full of fluid you could hear her breathing from across the room. So, we had to do as the family and dr wished. Put her on bipap, put in an iv, push lasix yadda, yadda yadda. I believe these were comfort measures because it did help her breathing but the poor lady just wanted to be free from her pain. She did pass later that night.
Is this common where you guys work?
I worked in a nursing home for 10 years. We don't decide when to send someone to the ER. That's the family. We feel exactly the same way when we have to send someone we know is dying to the ER. We would rather have the patient die "at home" in the nursing home, surrounded by people they know and who truly care about them (not that I'm saying ER nurses don't care so don't jump on me , it's different to spend months/years caring for someone then a few minutes or hours). We also want to be the ones to comfort the family who has known us for months/years.
Trust me, there is much, much, MUCH more paperwork in sending someone to the ER than if a patient passes.
It drives me crazy the EMTs would have the same attitude when we called 911 for a full code. WE DON'T GET TO DECIDE!!!! It makes us CRAZY to call you so please don't look at us like we're stupid. We don't have any control in what the family decides to do. Yes, I said this once to an EMT who started basically throwing a temper tantrum about how 'stupid' nursing home nurses were for calling them.
"It drives me crazy the EMTs would have the same attitude when we called 911 for a full code. WE DON'T GET TO DECIDE!!!! It makes us CRAZY to call you so please don't look at us like we're stupid. We don't have any control in what the family decides to do. Yes, I said this once to an EMT who started basically throwing a temper tantrum about how 'stupid' nursing home nurses were for calling them."
For the first pt I was talking about, it wasn't the family's decision to send her to the ER. They were quit upset that she was sent to us. In this instance, and I know because I talked to the nurse who sent her out, it was HER decision. The nurse.
I am not going to get into a Pi$$ing match over the rights and wrongs of sending out LTC pt's and who decides and all that stuff. I have never, nor will I ever, work in LTC. I don't know the process you gals go through in sending people out.
But what I will tell you is it REALLY MAKES ME MAD in situations like I described in my original post, that these poor people are being sent to the ER to die! I am sure there are facilities out there that are awesome, and don't send out pt's who are actively passing. AND THIS IS NOT a "stupid LTC nurse sent her out" kinda a post. It is about not respecting out elder's wishes to pass with peace. Not allowing another human being to stay in the comforts of their bed and surrondings. Maybe because when I see a elderly pt like that I see a grandma, a pappy, a mom or a dad and it gets a little personal and I think what if this was my family member. And with anyone who passes in the ER that I took care of, I grieve a little for the family. I even shed a few tears too.
Specializes in emergency, neuroscience and neurosurg..
Kudos to you.... for being the nurse we are all supposed to be and thinking of the patient first. And second kudos for standing up for nurses everywhere; LTC, ED, floor nurses, etc.. It drives me insane when another nurse talks down to/about nurses just because they aren't ED nurses. LTC nurses are still nurses their skills are different than ours in the ED but they are still a valuable member of the team. There are good and bad in both environments and where you work is not the deciding factor. Worse still is how anyone (insert EMT) who is not a nurse feels they have the right and/or knowledge base to pass judgement on the competency of a nurse. I was a CNA and LPN before becoming an RN and have also sat for and passed, as well as worked as an EMT-P and there is a distinct difference in the preparation at all levels. Until you are qualified yourself at the same level then you really cannot pass judgement on those that are.
As for the LTC patients being brought to the ED, locally we see this often. It is the result of panicking family members with little education on what to expect when time of death finally arrives and many many times the result of nursing staff that send the patients out so not to upset the other residents living at the LTC center. I was told once it is their home too and they don't want someone dying there. This is almost a subculture of thinking that presents itself too frequently. In my state also patients do not have to be AND/DNR to be placed on hospice..... I'm not sure what the thought is there but it happens sometimes.
Just today I dealt with a horrified daughter of an 80 year old LTC resident. She just couldn't believe I was suggesting to let her Mother die (she refused to hear the word "peacefully") or that Mom could benefit from hospice. I swear she looked at me as if I had 3 eyes and 2 purple horns growing out of my head. .
Just an update on this part of my previous post. My resident died peacefully this week with her husband and children by her side and hospice in place. Took a lot of talking and educating but I did get the job done.
If I had a dollar for everytime a DNR/DNI pt was resuscitated in our Er... My initial impression is that it has to do with family concern and misinformation. What sometimes upsets me is how overzealously we try to fix them before making every reasonable attempt to communicate with the pt and or family about the patients wishes. There is a doctor I work with who is very persistent about getting this information and I appreciate that so much when he is there.
Granted she was getting a pretty hefty dose of morphine Q1 hour, but her lungs were diminished in the bases and full of fluid you could hear her breathing from across the room. So, we had to do as the family and dr wished. Put her on bipap, put in an iv, push lasix yadda, yadda yadda. I believe these were comfort measures because it did help her breathing but the poor lady just wanted to be free from her pain. She did pass later that night.
The poor hospice nurse was doing everything she could, trying to keep her home and comfortable.
, it's different to spend months/years caring for someone then a few minutes or hours). We also want to be the ones to comfort the family who has known us for months/years. 
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bubblymom373
123 Posts
It sounds like more education is needed in regards to the role of Hospice in a facility. Those poor patients.